NURSES POCKET NOTES

NORMAL VALUES
LUNG SOUNDS
Crackles or
Crackling or rattling sounds
rales
wheezing
High-pitched whistling
expirations
stridor
Harsh, high-pitched
inspirations
rhonchi
Coarse, gravelly sounds
PULSE OXIMETRY
Range
Value

Treatment

Normal

95-100%

None or placebic

Mild
hypoxia
Moderate
hypoxia
Severe
hypoxia

91-94%

Give oxygen

86-90%

Give 100% oxygen

<85%

Give 100% oxygen

with positive
pressure

Albumin

3.2 g/dl

Alkaline Phosphatase
(Adults: 25-60)
Adults: >61yo

33-131 IU/L

Ammonia

20-70 mcg/dl

Bilirubin, direct

0-0.3 mg/dl

Bilirubin, tota

0.1-1.2 mg/dl

51-153 IU/L

BLOOD GASES
Arterial
pH
7.35-7.45
pCO2
35-45

Venous
7.32-7.42
38-52

pO2

70-100

28-48

HCO3

19-25

19-25

O2 Sat %

90-95

40-70

BUN

7-20 mg/dl

COMPLETE BLOOD COUND (CBC) ADULTS

Male
Female
Hemoglobin (g/dl)
13.5-16.5
12.015.0
Hematocrit (%)
41-50
36-44

RBCs (x106/ml)

45-55

RDW (RBC
distribution width)
MCV

<14.5

MCH

26-34

MCHC %

31-37

Platelet count

100000450000

40-49

80-100

CREATININE KINASE (CK) ISOENZYMES

CK-BB
0%
CK-MB (cardiac)
0-3.9%
CK-MM
96-100%
Creatinine Phosphakinase
8-150 IU/L
(CPK)
Creatinine (mg/dl)
0.5-1.4
ELECTROLYTES
Calcium
Calcium, ionized
Chloride
Magnesium
Phosphate
Potassium
Sodium
Ferritin (ng/ml)
Folate (ng/ml)
Glucose, fasting
Glucose (2 hours postprandial)
(mg/dl)
Hemoglobin A10
Iron (mcg/dl)
Lactic acid (mEq/L)
LDH (lactic dehydrogenase)

8.5-10.2mg/dl
2.242.46mEq/L
95-107 mEq/L
1.6-2.4mEq/L
2.5-4.5 mg/dl
3.5-5.2 mEq/L
135-145
mEq/L
13-300
3.6-20
60-110
(mg/dl)
Up to 140
6-8
65-150
0.7-2.1
56-194 IU/L

LIPOPROTEINS AND TRIGLYCERIDES

Cholesterol, total
<200 mg/dl
HDL cholesterol
30-70 mg/dl
LDL cholesterol
65-180 mg/dl
Triglycerides
45-155 mg/dl (<160)
Osmolality
289-308 mOsm/kg

SGOT (AST)
<35 IU/L (20-40)
SGPT (ALT)
<35 IU/L
THYROID FUNCTION TESTS
Free T3
2.3-4.2 pg/ml
Serum T3
70-200 ng/dl
Free T4
0.5-2.1 ng/dl
Serum T4
4.0-12.0mcg/dl
TSH
0.25-4.30 microunits/ml
Total iron binding capacity 250-420 mcg/dl
(TIBC)
Transferrin
>200 mg/dl
Uric acid (male)
2.0-8.0 mg/dl
Uric acid (female)
2.0-7.5 mg/dl
WBC + DIFFERENTIAL
WBC (cells/ml)
Segmented
neutrophils
Band forms
Basophils
Eosinophils
Lymphocytes
monocytes

4500-10000
54-62%
3-5% (above 8% indicates
left shif)
0-1 (0-0.75%)
0-3 (1-3%)
24-44 (25-33 %)
3-6 (3-7%)

NURSING CONSIDERATIONS FOR BT

Confirm that the transfusion is prescribed

Check if Px blood has been typed and crossmatched

Verify the consent from has been signed

Explain the procedure to the Px and instruct

px for s/sx of transfusion reaction (itching,
hives, chills, sweeling, fever, shortness of
breath)

Take pxs vital signs to establish baseline for

comparing of vital signs during transfusion

Standard precaution during BT as per hospital

policy

Use gauge 20 or larger needles for BT

Maximum hours for BT is 4 hours

Double check obtained PRBC from blood bank

Double check labes with other RN or MD to

make sure of ABO and Rh compatibility

Check blood for unusual color, bubbles or

cloudiness, it may indicate bacterial growth or
hemolysis

Make sure PRBC is initiated within 30 minutes

after removal from blood bank refrigerator
For first 15 minutes, run transfusion slowly not
more than 5ml/min, observe for side effects,
then increase flow rate unless px is risk for
circulatory overload.
Observe px frequently for 15 to 30 minutes
Be alert for adverse reactions, circulatory
overload, sepsis, febrile reactions, allergic
reactions and hemolytic reactions.
Change tubing after every 2 units transfused
Obtain BS and compare with initial VS
Document procedure
Monitor px for response to and effectiveness
of the procedure

Drug
Adrenaline
atSO4
Aminophylline
Aeknil
Benadryl
Burinex
Ca gluconate
Cardepine
Carricor
Calmegic
Cefamandole
Cefuroxime
Cordarone
Cyklokapron
Demerol
Dexamethasone
Dextrose
Diazepam
Diclofenac Na
(Voltaren)
Dilantin
Dobutrix
Dopamine
Dormicum
Ephedrine
Famotidine
Furosemide
Hyosine Hbr.
Isoket

Use
Bronchodilator cdc stim. &
vasoconstrictor
Anticholinergic
Bronchodilator
Anti-pyretic
Anti-histamine
Diuretic
Electrolyte modifier
Ca antagonist
Anti-arrhythmic
Analgesic/ anti-pyretic
Anti-infective
Anti-infective
Anti-arrhythmic
Coagulant
Narcotic agent
Anti-inflammatory
Caloric agent
Sedative
Non-steroidal antiinflammatory agent
Anti-convulsant; atniarrythmic
Inotropic agent
Vasopressor, inotropic agent
Sedative
Bronchodilator
Anti-ulcer
Diuretic
Antispasmodic
Anti-angina

Isoptin
Isotonic NaCl
KCl
Lanoxin
Cystine Acetate
Losec
MgSO4
Morphine
Metochlorpramide
Narcan
Nicardipine
Nubain
NaHCO3
Nitroprusside
Nipride
Nimotop
NTG (transderm)
Nitrobid
Orudis
Promethazine HCl
Perlinganit
Reglan
Sensorcain HCl
Solucortef
Toradol
Zantac
Zofran
Zinacef

Ca channel blocker, antianginal, anti-hypertension,

anti-arrhythmic
Elec. Mod.
Elec. Mod.
Digitalis
Analgesic
Anti-ulcer
Anti-convul
Narcotic anal
Anti-emetic
Narc. Antag
Ca channel blocker, antiangina, vasodilator, antihypertension
Narc. Analg.
Elec. Mod., alk. Agent
Anti-hpn
Cal channel blocker
Atni-ang., vasodil
Vasodil, anti-angi
Anti-inflam
Anti-histamine, anti-emetic,
sed
Anti-angina
Anti-emetic
Adrenalien
Immune response & inflame
Supp.
Analgesic
Anti-histamine receptor
Anti-emetic
Anti-infective

What is the normal value of

60-110 mg/dl
serum glucose?
What is the normal arterial
7.35 to 7.45
blood pH value?
What is the normal PaC02?
35-45 mmHg
Normal Pa02?

80-100mmHg

Normal HC03?

22-28 mEq

Normal value of K?

3.5 to 5.5 mEq/l

Normal serum sodium level?

135-145 mEq/l

Normal BUN?

8-25 mg/dl

Normal blood osmolarity?

If a patient's level of
Creatine kinase (isoenzyme
MB) is high, what does this
mean?
If a patient's level of
Creatine kinase (isoenzyme
BB) is high, what does this
mean?
If a patient's level of
Creatine kinase (isoenzyme
MM) is high, what does this
mean?
If LDH-1 is high, what does
it mean? (lactate
dehydrogenase isoenzyme
1)
If LDH-5 is high, what does
it mean? (lactate
dehydrogenase isoenzyme
5)
If AST level is elevated,
what does that mean?
(Aspartate
aminotransferase)
If ALT level is elevated, what
does that mean? (Alanine
aminotransferase)

275-295 mOs/kg

What is significance of
elevated amylase?
Normal value of total
bilirubin?

Pancreas, salivary gland

cell necrosis

Cell necrosis in heart.

Cell necrosis in brain

Cel necrosis in heart or

skeletal muscle
Cell necrosis of heart,
erythrocytes, or skeletal
muscle
Cell necrosis of Liver or
skeletal muscle

Cell necrosis of heart, liver

skeletal muscle
Cell necrosis of Liver,
skeletal muscle

.2 - 1.5 mg/dl

Normal value of direct

bilirubin?

0 to .3 mg/dl

Normal calcium levels

Serum (total) is 9.0 to 10.5,

ionized is 4.5 to 5.6. 50% of
calcium in blood is bound
to protein, 40% is free or
ionized.